EP3302564B1 - Inhibitor of igfbp3/tmem219 axis and diabetes - Google Patents

Inhibitor of igfbp3/tmem219 axis and diabetes Download PDF

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EP3302564B1
EP3302564B1 EP16728911.5A EP16728911A EP3302564B1 EP 3302564 B1 EP3302564 B1 EP 3302564B1 EP 16728911 A EP16728911 A EP 16728911A EP 3302564 B1 EP3302564 B1 EP 3302564B1
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Prior art keywords
igfbp3
tmem219
diabetes
inhibitor
igf
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French (fr)
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EP3302564A1 (en
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Francesca D'ADDIO
Paolo Fiorina
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Ospedale San Raffaele SRL
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Ospedale San Raffaele SRL
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Priority claimed from PCT/EP2016/062792 external-priority patent/WO2016193497A1/en
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/1703—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans from vertebrates
    • A61K38/1709—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans from vertebrates from mammals
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/70—Carbohydrates; Sugars; Derivatives thereof
    • A61K31/7088—Compounds having three or more nucleosides or nucleotides
    • A61K31/713—Double-stranded nucleic acids or oligonucleotides
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K16/00—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies
    • C07K16/18—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
    • G01N33/6893—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids related to diseases not provided for elsewhere
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/70—Immunoglobulins specific features characterized by effect upon binding to a cell or to an antigen
    • C07K2317/76—Antagonist effect on antigen, e.g. neutralization or inhibition of binding
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
    • G01N2333/435—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans
    • G01N2333/46—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans from vertebrates
    • G01N2333/47—Assays involving proteins of known structure or function as defined in the subgroups
    • G01N2333/4701—Details
    • G01N2333/4745—Insulin-like growth factor binding protein
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/04—Endocrine or metabolic disorders
    • G01N2800/042—Disorders of carbohydrate metabolism, e.g. diabetes, glucose metabolism
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/50—Determining the risk of developing a disease
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/52—Predicting or monitoring the response to treatment, e.g. for selection of therapy based on assay results in personalised medicine; Prognosis

Definitions

  • the present invention relates to the role of the IGFBP3/TMEM219 axis in the onset of diabetes and the related use of IGFBP3/TMEM219 axis inhibitors for the treatment and/or prevention of diabetes.
  • Gastrointestinal disorders consisting of gastroparesis, abdominal distension, irritable bowel syndrome and fecal incontinence, are common in individuals with type 1 diabetes (T1D)(1993). Indeed up to 80% of individuals with long-standing T1D, who are generally affected by several diabetic complications including end stage renal disease (ESRD)(1993; Atkinson et al., 2013; Fiorina et al., 2001), show intestinal symptoms. The presence of these gastrointestinal symptoms, known as diabetic enteropathy (DE), significantly reduces the quality of life (1993; Atkinson et al., 2013; Camilleri, 2007; Talley et al., 2001) and has a largely unknown pathogenesis (Feldman and Schiller, 1983).
  • ESRD end stage renal disease
  • DE diabetic enteropathy
  • Colonic stem cells located at the crypt base of the large intestine and expressing the ephrin B receptor 2 (EphB2), leucine-rich repeat containing G protein-coupled receptor 5 (LGR5), h-TERT and aldehyde dehydrogenase (Aldh), among other markers (Carlone and Breault, 2012; Carpentino et al., 2009; Jung et al., 2011; Sato and Clevers, 2013), constitute with the local microenvironment the CoSC niche (van der Flier and Clevers, 2009; Zeki et al., 2011).
  • EphB2 ephrin B receptor 2
  • LGR5 leucine-rich repeat containing G protein-coupled receptor 5
  • Aldh aldehyde dehydrogenase
  • diabetic enteropathy The treatment of gastrointestinal disorders, in particular diabetic enteropathy includes symptomatic drugs and reliever medications for diarrhea, abdominal pain, constipation, and dyspepsia. Up to date there is no specific treatment available for diabetic enteropathy.
  • the diagnosis of gastrointestinal disorders, in particular diabetic enteropathy includes colon endoscopy, gastric endoscopy, anorectal manometry, esophageal manometry and analysis of fecal samples, evaluation of peripheral cancer markers (i.e. CEA, Ca 19.9, alpha-fetoprotein, Ca125) and of celiac markers. None of the aforementioned method is capable of providing a certain diagnosis of diabetic enteropathy.
  • WO 2011133886 and WO2007024715 disclose a therapeutic composite in the form of a IGFBP3 binding antibody.
  • WO0187238 relates to an anticancer pharmaceutical composition comprising a therapeutically effective TMEM219, in particular for the treatment of colon cancer.
  • WO 2014089262 discloses the use of IGFBP3 as a marker of diagnosis of chronic inflammation (obesity) disorders (in particular, inflammatory bowel disease such as UC and Crohn's disease and colon cancer).
  • US6066464 relates to an immunoassay for the detection of IGFBP3 on a solid support that is paper.
  • WO2013152989 relates to the use of IGFBP3 as a biomarker of colorectal cancer.
  • WO0153837 discloses a method of monitoring or diagnosing disease conditions that involve measuring a combination of tumor markers and at least one component of the IGF axis.
  • IGFBP3 is proposed as a marker of colon tumors.
  • Type 1 diabetes has historically been regarded as a T cell-mediated autoimmune disease, resulting in the destruction of insulin-producing pancreatic beta cells(Bluestone et al., 2010; Eisenbarth, 1986).
  • an initiating factor triggers the immune response against autoantigens, and the subsequent newly activated autoreactive T cells target and further destroy the pancreatic islets and insulin-producing beta cells(Bluestone et al., 2010).
  • WO2008153788 claims a method to inhibit or reduce IGFBP3 levels to treat insulin resistance or TD2, wherein the inhibitor is a nucleic acid complementary to IGFBP3 mRNA or an antibody that binds IGFBP3, anti IGFBP-3.
  • the document is silent about the IGFBP3/TMEM219 axis.
  • Muzumdar et al. discloses that IGFBP3 acts as an insulin antagonist through a central mechanism leading to a reduced peripheral glucose uptake. This document does not disclose the inhibition of the IGFBP3/TMEM219 axis.
  • WO9739032 claims the use of an IGFBP3 inhibitor to treat diabetes, wherein the inhibitor prevents IGFBP-3 binding to IGF-1. Inhibition of IGFBP3/TMEM219 axis is not contemplated. D'Addio et al., (2015) indicates that eco-TEM219 normalize circulating IGF-I/IGFBP3 levels.
  • WO2007024715 relates to the use of engineered multivalent and multispecific binding proteins, namely dual variable domain immunoglobulins, which bind two different antigens or target peptides using a single middle linker and are bispecific. The document mentions among the numerous target proteins, IGFBP3 in combination with other members of the family.
  • WO2011133886 relates to a method of generating antibodies and other multimeric protein complexes, namely heteromutlimeric proteins, capable of specifically binding to more than one target.
  • IGFBP3 may represent a potential target.
  • IGFBP3 prevented mini-gut growth in vitro via a TMEM219-dependent/caspase-mediated IGF-I-independent effect and disrupted CoSCs in preclinical models in vivo.
  • the peripheral IGF-I/IGFBP3 dyad controls CoSCs and is dysfunctional in DE.
  • the present invention reports compelling data showing that IGFBP3 release is increased in individuals at high-risk for T1D and T2D.
  • the inventors have discovered that the IGFBP3 receptor, TMEM219, is expressed in a beta cell line and on murine/human islets, and that its ligation by IGFBP3 is toxic to beta cells, raising the possibility of the existence of an endogenous beta cell toxin.
  • beta cell toxin(s) [betatoxin(s)] may be involved in the pathogenesis of TD1, in particular in the early phase, when islet/beta cell injuries may facilitate the exposure of autoantigens to immune cells, thus creating a local inflamed environment and a sustained immune reaction.
  • authors have observed elevated levels of IGFBP3 in pre-T2D and in T2D individuals as well, suggesting that a potential role for this axis is also evident in T2D.
  • IGFBP3 may induce apoptosis of beta cells and of murine/human islets in vitro in a caspase 8-dependent manner.
  • the newly generated recombinant ecto-TMEM219 protein based on the TMEM219 extracellular domain, capable of quenching IGFBP3, prevents its signaling via TMEM219 on pancreatic beta cells.
  • Ecto-TMEM219 treatment reduces beta cell loss, improves islet insulin content and glycometabolic control in murine models of diabetes (T1D and T2D) in vivo, while in vitro it protects islets and beta cells from IGFBP3-induced apoptosis.
  • IGFBP3 is an endogenous peripheral beta cell toxin (or betatoxin ) that is increasingly released in individuals at high-risk for diabetes (T1D and T2D).
  • Concomitant expression of the IGFBP3 receptor (TMEM219) on beta cells initiates/facilitates beta cell death, thus favoring diabetes onset/progression.
  • the invention is based on the finding that TMEM219, the IGFBP3 receptor that mediates IGFBP3/IGF1 independent detrimental effects, is expressed on pancreatic islets and beta cells; moreover, targeting the IGFBP3/TMEM219 axis with ecto-TMEM219 re-establishes appropriate IGFBP3 signaling in diabetic mice and prevents beta cell loss and preserves islet morphology, thereby confirming the critical role of the IGFBP3/TMEM219 axis in favoring beta cell loss in diabetes.
  • the present therapeutic approach may overcome the limits of the current therapies for T1D and T2D as it could prevent the beta cell damage and the consequent reduced or abolished insulin secretion that leads to the development of diabetes.
  • the invention provides an inhibitor of IGFBP3/TMEM219 axis for use in the treatment and/or prevention of diabetes in a subject wherein said inhibitor is a fragment of the receptor TMEM219, said fragment comprising an extracellular domain of TMEM219.
  • said inhibitor is a polynucleotide coding for the fragment of the receptor TMEM219 as defined above or a vector comprising or expressing the polynucleotide or a host cell genetically engineered expressing the fragment of the receptor TMEM219 as defined above or the polynucleotide.
  • the inhibitor is ecto-TMEM219.
  • the inhibitor is soluble or pegylated.
  • said inhibitor is a fusion protein TMEM219-Ig, preferably said fusion protein quenches circulating IGFBP3 and prevents its binding to TMEM219.
  • the diabetes is Type-1 or Type-2 diabetes.
  • the subject is selected from the group consisting of: a subject at risk of developing Type-1 and/or Type-2 diabetes, a subject with early stage Type-1 and/or Type-2 diabetes.
  • the present invention also provides a pharmaceutical composition for use in the treatment and/or prevention of diabetes comprising the inhibitor as defined above and pharmaceutically acceptable carriers.
  • the pharmaceutical composition further comprises a therapeutic agent.
  • the therapeutic agent is selected from the group consisiting of: insulin in any form, Pramlintide (Symlin), angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), Aspirin, Cholesterol-lowering drugs.
  • Pramlintide Symlin
  • ACE angiotensin-converting enzyme
  • ARBs angiotensin II receptor blockers
  • Aspirin Cholesterol-lowering drugs.
  • Metformin Glucophage, Glumetza, others
  • Sulfonylureas glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl)
  • Meglitinides for instance repaglinide (Prandin) and nateglinide (Starlix)
  • Thiazolidinediones Roslitazone (Avandia) and pioglitazone (Actos) for examples
  • DPP-4 inhibitors sitagliptin (Januvia), saxagliptin (Onglyza) and linagliptin (Tradjenta)
  • GLP-1 receptor agonists Exenatide (Byetta) and liraglutide (Victoza)
  • SGLT2 inhibitors examples include canagliflozin (Invokana) and dapagliflozin (Farxiga).
  • inhibiting the IGFBP3/TMEM219 axis means blocking IGFBP3 binding to TMEM219, for instance by quenching IGFBP3 from the circulation, it also means blocking the IGFBP3-binding site of TMEM219, blocking IGFBP3 binding site on TMEM219. It further means inhibiting TMEM219 function and/or expression and/or signaling, this may be achieved for instance by silencing TMEM219 expression, in particular with SiRNA or oligonucleotides. It also means inhibiting the function and/or expression of IGFBP3.
  • an inhibitor of IGFBP3 binding to TMEM219 can be one of the following molecules:
  • the patient that may be treated are individuals who are at risk for developing T1D (autoimmune diabetes, based on the presence of peripheral anti-islet autoantibodies or genetic predisposition or familiar predisposition or altered beta cell function) or T2D (non autoimmune diabetes based on the evidence of an impaired fasting glucose and/or impaired glucose tolerance without fulfilling the criteria for the diagnosis of diabetes), or individuals who develop T1D or T2D in any stage of the disease, in particular a subject with early stage Type-1 and/or Type-2 diabetes, with the purpose of protecting beta cells from further destruction.
  • T1D autoimmune diabetes, based on the presence of peripheral anti-islet autoantibodies or genetic predisposition or familiar predisposition or altered beta cell function
  • T2D non autoimmune diabetes based on the evidence of an impaired fasting glucose and/or impaired glucose tolerance without fulfilling the criteria for the diagnosis of diabetes
  • individuals who develop T1D or T2D in any stage of the disease in particular a subject with early stage Type-1 and/or Type-2 diabetes, with the purpose of protecting beta
  • IGFBP3 may be measured by means of RT-PCR on tissues and cells, Western blot on tissues and cells, Immunohistochemistry on tissues, Immunofluorescence on tissue and cells. Levels of IGFBP3 in biological fluids can be measured by immune-targeted assays and proteomic analysis.
  • IGFBP3 The function of IGFBP3 may be measured by means of detecting Caspases 8 and 9 expression on target cells using RT-PCR, microarrays, by co-culturing target cells/structures with Pan Caspase inhibitor, Caspases 8 and 9 inhibitors and measuring live cells/structures.
  • inhibitor or block the interaction of IGFBP3 with its receptor TMEM219 means quenching circulating IGFBP3 and preventing its binding to TMEM219 receptor expressed on pancreatic islets and beta cells.
  • the IGFBP3-TMEM219 binding could be prevented also by the use of an IGFBP3- blocking antibody.
  • a TMEM219 blocking antibody could bind TMEM219 receptor thus rendering the receptor unavailable when IGFBP3 comes from the circulation.
  • the inhibitor of the invention may be a fragment of TMEM219 comprising an extracellular domain of TMEM219 (ecto-TMEM219), in particular the fragment comprises the sequence:
  • the fragment of TMEM219 is an extracellular domain of TMEM219 , in particular the fragment comprises the sequence:
  • the fragment of TMEM219 consists of:
  • the fragment of TMEM219 consists of:
  • TMEM219 is preferably eukaryote TMEM219, preferably a mammal TMEM219, still preferably human TMEM219.
  • the interaction of IGFBP3 with TMEM219 may be measured by means of indirect assessment of the effects of IGFBP3 on target cells (increased Caspase 8 and 9 expression with RT-PCR), direct assessment of IGFBP3-IGFBP3-receptor (TMEM219) binding with Liquid or Solid Phase Ligand Binding Assays (i.e. immunoprecipitation, RT-PCR, immunoassays) and Nonradioactive Ligand Binding Assays.
  • long-standing TID means a history of type 1 diabetes longer than 15 years associated with the development of diabetic complications.
  • the above vector is an expression vector selected from the group consisting of: plasmids, viral particles and phages.
  • said host cell is selected from the group consisting of: bacterial cells, fungal cells, insect cells, animal cells, plant cells, preferably being an animal cell, more preferably a human cell.
  • the inhibitor as above defined (a) is combined with at least one therapeutic agent (b) to define a combination or combined preparation.
  • the therapeutic agent may be an anti-diabetic agent, an agent used to prevent diabetes, an anti-apoptotic agent, an anti-diabetes models and effects seen in man suggest that synergy in animals may e.g. be demonstrated in the models as described in the Examples below.
  • compositions are preferably for systemic, oral, locally, preferably rectally, or topical administration.
  • Control amount is the amount measured in a proper control.
  • Control means can be used to compare the amount or the increase of amount of the compound as above defined to a proper control.
  • the proper control may be obtained for example, with reference to known standard, either from a normal subject or from normal population.
  • the above diagnosis method may also comprise a step of treating the subject, in particular the treatment may be an inhibitor of IGFBP3/TMEM219 axis as defined in the present invention or an existing treatment for diabetes such as indicated above.
  • the means to measure the amount of IGFBP3 as above defined are preferably at least one antibody, functional analogous or derivatives thereof. Said antibody, functional analogous or derivatives thereof are specific for said compound.
  • the kit of the invention comprises:
  • kits according to the invention can further comprise customary auxiliaries, such as buffers, carriers, markers, etc. and/or instructions for use.
  • the proper control may be a sample taken from a healthy patient or from a patient affected by a disorder other than diabetes.
  • the progress of the disease is monitored and the proper control may be a sample taken from the same subject at various times or from another patient, and the proper control amount may by the amount of the same protein or polynucleotide measured in a sample taken from the same subject at various times or from another patient.
  • the proper control may by a sample taken from the same subject before initiation of the therapy or taken at various times during the course of the therapy and the proper control amount may be the amount of the same protein or polynucleotide measured in a sample taken from the same subject before initiation of the therapy or taken at various times during the course of the therapy.
  • the therapy may be the therapy with the inhibitor of the present invention.
  • the expression "measuring the amount” can be intended as measuring the amount or concentration or level of the respective protein and/or mRNA thereof and/or DNA thereof, preferably semi-quantitative or quantitative.
  • Measurement of a protein can be performed directly or indirectly.
  • Direct measurement refers to the amount or concentration measure of the biomarker, based on a signal obtained directly from the protein, and which is directly correlated with the number of protein molecules present in the sample.
  • This signal - which can also be referred to as intensity signal - can be obtained, for example, by measuring an intensity value of a chemical or physical property of the biomarker.
  • Indirect measurements include the measurement obtained from a secondary component (e.g., a different component from the gene expression product) and a biological measurement system (e.g. the measurement of cellular responses, ligands, "tags” or enzymatic reaction products).
  • amount refers but is not limited to the absolute or relative amount of proteins and/or mRNA thereof and/or DNA thereof, and any other value or parameter associated with the same or which may result from these.
  • values or parameters comprise intensity values of the signal obtained from either physical or chemical properties of the protein, obtained by direct measurement, for example, intensity values in an immunoassay, mass spectroscopy or a nuclear magnetic resonance. Additionally, these values or parameters include those obtained by indirect measurement, for example, any of the measurement systems described herein. Methods of measuring mRNA and DNA in samples are known in the art.
  • the cells in a test sample can be lysed, and the levels of mRNA in the lysates or in RNA purified or semi-purified from lysates can be measured by any variety of methods familiar to those in the art. Such methods include hybridization assays using detectably labeled DNA or RNA probes (i.e., Northern blotting) or quantitative or semi-quantitative RT-PCR methodologies using appropriate oligonucleotide primers. Alternatively, quantitative or semi-quantitative in situ hybridization assays can be carried out using, for example, tissue sections, or unlysed cell suspensions, and detectably labeled (e.g., fluorescent, or enzyme-labeled) DNA or RNA probes. Additional methods for quantifying mRNA include RNA protection assay (RPA), cDNA and oligonucleotide microarrays, representation difference analysis (RDA), differential display, EST sequence analysis, and serial analysis of gene expression (SAGE).
  • RPA RNA protection assay
  • RDA representation difference
  • the subject may present the disease or go towards an aggravation of said disease.
  • the subject may be not affected by the disease or go toward an amelioration of the disease, respectively.
  • the expression “detection” or “measuring the amount” is intended as measuring the alteration of the molecule.
  • Said alteration can reflect an increase or a decrease in the amount of the compounds as above defined.
  • An increase of the protein IGFBP3 or of the polynucleotide coding for said protein can be correlated to an aggravation of the disease.
  • a decrease the protein IGFBP3 or of the polynucleotide coding for said protein can be correlated to an amelioration of the disease or to recovery of the subject.
  • protein IGFBP3 or “IGFBP3” or “TMEM219” is intended to include also the corresponding protein encoded from a IGFBP3 or TMEM orthologous or homologous genes, functional mutants, functional derivatives, functional fragments or analogues, isoforms thereof.
  • gene IGFBP3 or “IGFBP3” or “gene TMEM219” or “TMEM219” is intended to include also the corresponding orthologous or homologous genes, functional mutants, functional derivatives, functional fragments or analogues, isoforms thereof.
  • mutants of the protein are mutants that may be generated by mutating one or more amino acids in their sequences and that maintain their activity for the treatment of diabetes.
  • the protein of the invention if required, can be modified in vitro and/or in vivo, for example by glycosylation, myristoylation, amidation, carboxylation or phosphorylation, and may be obtained, for example, by synthetic or recombinant techniques known in the art.
  • the protein of the invention "IGFBP3" or “TMEM219” may be modified to increase its bioavailability or half-life by know method in the art.
  • the protein may be conjugated to a polymer, may be pegylated ect.
  • the active ingredients may also be entrapped in microcapsule prepared, for example, by coacervation techniques or by interfacial polymerization, for example, hydroxymethylcellulose or gelatin-microcapsule and poly-(methylmethacylate) microcapsule, respectively, in colloidal drug delivery systems (for example, liposomes, albumin microspheres, microemulsions, nano-particles and nanocapsules) or in macroemulsions.
  • colloidal drug delivery systems for example, liposomes, albumin microspheres, microemulsions, nano-particles and nanocapsules
  • the formulations to be used for in vivo administration must be sterile. This is readily accomplished by filtration through sterile filtration membranes.
  • Sustained-release preparations may be prepared. Suitable examples of sustained-release preparations include semipermeable matrices of solid hydrophobic polymers containing the antibody, which matrices are in the form of shaped articles, e.g., films, or microcapsule. Examples of sustained-releabe matrices include polyesters, hydrogels (for example, poly(2-hydroxyethyl-methacrylate), or poly(vinylalcohol)), polylactides ( U.S. Pat. No.
  • copolymers of L-glutamic acid and [gamma] ethyl-L-glutamate non-degradable ethylene-vinyl acetate
  • degradable lactic acid-glycolic acid copolymers such as injectable microspheres composed of lactic acid-glycolic acid copolymer and leuprolide acetate
  • poly-D-(-)-3-hydroxybutyric acid While polymers such as ethylene- vinyl acetate and lactic acid-glycolic acid enable release of molecules for over 100 days, certain hydrogels release proteins for shorter time periods.
  • encapsulated antibodies When encapsulated antibodies remain in the body for a long time, they may denature or aggregate as a result of exposure to moisture at 37°C, resulting in a loss of biological activity and possible changes in immunogenicity. Rational strategies can be devised for stabilization depending on the mechanism involved. For example, if the aggregation mechanism is discovered to be intermolecular S- S bond formation through thio-disulfide interchange, stabilization may be achieved by modifying sulfhydryl residues, lyophilizing from acidic solutions, controlling moisture content, using appropriate additives, and developing specific polymer matrix compositions.
  • analogue as used herein referring to a protein means a modified peptide wherein one or more amino acid residues of the peptide have been substituted by other amino acid residues and/or wherein one or more amino acid residues have been deleted from the peptide and/or wherein one or more amino acid residues have been deleted from the peptide and or wherein one or more amino acid residues have been added to the peptide.
  • Such addition or deletion of amino acid residues can take place at the N-terminal of the peptide and/or at the C-terminal of the peptide.
  • derivative as used herein in relation to a protein means a chemically modified peptide or an analogue thereof, wherein at least one substituent is not present in the unmodified peptide or an analogue thereof, i.e. a peptide which has been covalently modified. Typical modifications are amides, carbohydrates, alkyl groups, acyl groups, esters and the like. As used herein, the term “derivatives” also refers to longer or shorter polypeptides having e.g.
  • a percentage of identity of at least 41 % preferably at least 41.5%, 50 %, 54.9% , 60 %, 61.2%, 64.1%, 65 %, 70 % or 75%, more preferably of at least 85%, as an example of at least 90%, and even more preferably of at least 95% with IGFBP3, or with an amino acid sequence of the correspondent region encoded from a IGFBP3 orthologous or homologous gene.
  • fragments refers to polypeptides having preferably a length of at least 10 amino acids, more preferably at least 15, at least 17 amino acids or at least 20 amino acids, even more preferably at least 25 amino acids or at least 37 or 40 amino acids, and more preferably of at least 50, or 100, or 150 or 200 or 250 or 300 or 350 or 400 or 450 or 500 amino acids.
  • an "effective amount" of a composition is one that is sufficient to achieve a desired biological effect, in this case an amelioration or the treatment of diabetes.
  • the effective dosage will be dependent upon the age, sex, health, and weight of the recipient, kind of concurrent treatment, if any, frequency of treatment, and the nature of the effect desired.
  • the provided ranges of effective doses of the inhibitor or molecule of the invention e.g. from 1 mg/kg to 1000 mg/kg, in particular systemically administered
  • the preferred dosage can be tailored to the individual subject, as is understood and determinable by one of skill in the art, without undue experimentation.
  • oligonucleotides of the present invention may be carried out by known methods, wherein a nucleic acid is introduced into a desired target cell in vitro or in vivo.
  • An aspect of the present invention comprises a nucleic acid construct comprised within a delivery vehicle.
  • a delivery vehicle is an entity whereby a nucleotide sequence can be transported from at least one media to another. Delivery vehicles may be generally used for expression of the sequences encoded within the nucleic acid construct and/or for the intracellular delivery of the construct. It is within the scope of the present invention that the delivery vehicle may be a vehicle selected from the group of RNA based vehicles, DNA based vehicles/vectors, lipid based vehicles, virally based vehicles and cell based vehicles.
  • delivery vehicles include: biodegradable polymer microspheres, lipid based formulations such as liposome carriers, coating the construct onto colloidal gold particles, lipopolysaccharides, polypeptides, polysaccharides, pegylation of viral vehicles.
  • a virus as a delivery vehicle, where the virus may be selected from: adenoviruses, retroviruses, lentiviruses, adeno-associated viruses, herpesviruses, vaccinia viruses, foamy viruses, cytomegaloviruses, Semliki forest virus, poxviruses, RNA virus vector and DNA virus vector.
  • viruses are well known in the art.
  • cationic liposomes are e.g. Tfx 50 (Promega) or Lipofectamin 2000 (Life Technologies).
  • compositions of the present invention may be in form of a solution, e.g. an injectable solution, a cream, ointment, tablet, suspension or the like.
  • the composition may be administered in any suitable way, e.g. by injection, particularly by intraocular injection, by oral, topical, nasal, rectal application etc.
  • the carrier may be any suitable pharmaceutical carrier.
  • a carrier is used, which is capable of increasing the efficacy of the RNA molecules to enter the target-cells. Suitable examples of such carriers are liposomes, particularly cationic liposomes.
  • the recombinant expression vector of the invention can be any suitable recombinant expression vector, and can be used to transform or transfect any suitable host.
  • Suitable vectors include those designed for propagation and expansion or for expression or both, such as plasmids and viruses.
  • the recombinant expression vectors of the invention can be prepared using standard recombinant DNA techniques. Constructs of expression vectors, which are circular or linear, can be prepared to contain a replication system functional in a prokaryotic or eukaryotic host cell. Replication systems can be derived, e.g., from CoIE1, 2 ⁇ plasmid, ⁇ , SV40, bovine papilloma virus, and the like.
  • the recombinant expression vector comprises regulatory sequences, such as transcription and translation initiation and termination codons, which are specific to the type of host (e.g., bacterium, fungus, plant, or animal) into which the vector is to be introduced, as appropriate and taking into consideration whether the vector is DNA- or RNA- based.
  • the recombinant expression vector can include one or more marker genes, which allow for selection of transformed or transfected hosts. Marker genes include biocide resistance, e.g., resistance to antibiotics, heavy metals, etc., complementation in an auxotrophic host to provide prototrophy, and the like.
  • Suitable marker genes for the inventive expression vectors include, for instance, neomycin/G418 resistance genes, hygromycin resistance genes, histidinol resistance genes, tetracycline resistance genes, and ampicillin resistance genes.
  • the recombinant expression vector can comprise a native or normative promoter operably linked to the nucleotide sequence encoding the PCYOX1 inhibitor (including functional portions and functional variants thereof), or to the nucleotide sequence which is complementary to or which hybridizes to the nucleotide sequence encoding the RNA.
  • promoters e.g., strong, weak, inducible, tissue- specific and developmental-specific, is within the ordinary skill of the artisan.
  • the promoter can be a non-viral promoter or a viral promoter, e.g., a cytomegalovirus (CMV) promoter, an SV40 promoter, an RSV promoter and a promoter found in the long-terminal repeat of the murine stem cell virus.
  • CMV cytomegalovirus
  • inventive recombinant expression vectors can be designed for either transient expression, for stable expression, or for both. Also, the recombinant expression vectors can be made for constitutive expression or for inducible expression.
  • the compounds of this invention can also be administered in sustained release forms or from sustained release drug delivery systems.
  • sustained release materials can also be found in the incorporated materials in Remington's Pharmaceutical Sciences.
  • pharmaceutical formulations can be prepared using a process, which is generally known in the pharmaceutical art.
  • the molecule of the invention when administered with another therapeutic agent, it may be administered simultaneously or sequentially.
  • IGFBP3 Homo sapiens insulin-like growth factor binding protein 3 (IGFBP3), RefSeqGene on chromosome 7, NCBI Reference Sequence: NG_011508.1
  • IGFBP3 Homo sapiens insulin-like growth factor binding protein 3 (IGFBP3), transcript variant 1, mRNA, NCBI Reference Sequence: NM_001013398.1
  • TMEM219 transmembrane protein 219 [ Homo sapiens (human)], Gene ID: 124446.
  • TMEM219 Homo sapiens transmembrane protein 219 (TMEM219), transcript variant 1, mRNA, NCBI Reference Sequence: NM_001083613.1
  • T1D+ESRD pancreas-kidney transplantation
  • SPK pancreas-kidney transplantation
  • T1D+ESRD 60 individuals with T1D+ESRD registered on the waiting list for simultaneous pancreas-kidney transplantation (SPK) matched for (age 41 to 43 years old), gender, and duration of T1D (29.4 ⁇ 1.8 years) were enrolled in the study.
  • CTRL age and gender
  • T1D+ESRD subjects were all on intensive insulin treatment at the time of enrollment in the study, while the CTRL group was not being administered any medication. All T1D+ESRD subjects were on the same treatment as antiplatelet therapy (ASA) and anti-hypertension (angiotensin-converting-enzyme inhibitors), while 40 out of 60 received statins when enrolled in the study.
  • ASA antiplatelet therapy
  • anti-hypertension angiotensin-converting-enzyme inhibitors
  • Individuals taking an oral anticoagulant agent were not included.
  • SPK individuals were all insulin-independent for the entire follow-up period, whereas K+T1D individuals were on intensive subcutaneous insulin therapy. All subjects provided informed consent before study enrollment. Studies not included in the routine clinical follow-up were covered by an appropriate Institutional Review Board approval (Enteropatia-trapianto/01 Secchi/Fiorina).
  • Organs for transplantation were obtained from deceased donors through the "North Italia Transplant" organ procurement consortium (NITp, Milan). After induction with ATG (thymoglobulin, IMTIX, SANGSTAT), immunosuppression was maintained using cyclosporine (through levels between 100-250 ng/ml) or FK506 (through levels between 10-15 ng/ml), mycophenolate mofetil (500-2000 mg/day), and methylprednisolone (10 mg/day). Steroids were withdrawn within 3-6 months after transplantation. All patients included in the T1D+ESRD and SPK groups were on anti-platelet therapy (80% ASA and 20% ticlopidine) to prevent graft or fistula thrombosis.
  • glomerular filtration rate was calculated using the Modification of Diet in Renal Disease (MDRD) formula (Levey et al., 1999).
  • GSRS Gastrointestinal Symptom Rating Scale
  • Gastrointestinal symptoms were evaluated by GSRS questionnaire in healthy subjects, in long-standing T1D individuals (T1D+ESRD) and in SPK and K+T1D groups at 2, 4 and 8 years after transplantation.
  • the Gastrointestinal Symptom Rating Scale is a questionnaire consisting of 15 items with a seven-graded Likert scale defined by descriptive anchors(Svedlund et al., 1988). The questionnaire was originally constructed as an interview-based rating scale designed to evaluate a wide range of gastrointestinal symptoms and was later modified to become a self-administered questionnaire. The higher the scores, the more severe the symptoms: the scale ranges from a minimum value of 1 to a maximum value of 7.
  • the items can be grouped into five dimensions previously identified on the basis of a factor analysis: abdominal pain syndrome (three items), reflux syndrome (two items), indigestion syndrome (four items), diarrhea syndrome (three items) and constipation syndrome (three items).
  • Ki67 monoclonal, clone MIB1, 1:100 dilution, Dako, Carpinteria, CA, USA
  • aldehyde dehydrogenase monoclonal, clone 44/ALDH, 1:1000 dilution, Transduction Laboratories, Franklin Lakes, NJ, USA
  • EphB2 monoclonal, clone 48CT12.6.4, 1:200 dilution, Lifespan Biosciences, Seattle, WA, USA
  • LGR5 monoclonal, clone 2A2, 1:100 dilution, Origene Technologies, Rockville, MD, USA
  • hTERT monoclonal, clone Y182, 1:500 dilution, Millipore, Billerica, MA, USA
  • glicentin polyclonal, 1:1250 dilution, Milab, Malmo, Sweden
  • pancreatic polypeptide polyclonal, 1:500 dilution, Peninsula
  • Immunofluorescence samples obtained from liver biopsies were observed using a confocal system (LSM 510 Meta scan head integrated with the Axiovert 200 M inverted microscope; Carl Zeiss, Jena, Germany) with a 63x oil objective. Images were acquired in multitrack mode, using consecutive and independent optical pathways. The following primary antibodies were used: rabbit IGFBP3 (1:10, Sigma) mouse Hep Par-1 (1:20, monoclonal, Dako), mouse CD163 (1:10, cloneMRQ26, CellMarque).
  • mouse vimentin (1:80, monoclonal, clone: V9 Dako)
  • mouse Aldheyde (1:1000, monoclonal, clone: 44, BD)
  • mouse citocherain 20 (1:100, monoclonal, clone:Ks20.8, Dako)
  • Synaptofisin (1:100, monoclonal, clone: syn88, BioGenex).
  • Paraffin sections of human colon mucosa were de-paraffinized and re-hydrated according to standard procedures. After treatment of sections using 0.2M HCl for 15 minutes at room temperature, sections were washed 3 times in PBS and incubated for 15 min at 37°C in proteinase K (30 ⁇ g/ml in PBS). 0.2% glycine in PBS was added for 1 minute in order to neutralize Proteinase K activity, and samples were washed twice in PBS.
  • the digoxigenin-labelled probe was diluted 750 ng/ml in hybridization solution and incubated for 24 hrs at 65°C. Post-hybridization washes were performed 3X 20 min in 50% Formamide / 2XSSC at 65°C. Sections were rinsed in TBS-T buffer (0.1M TrisHCl pH7.5, 0.15M NaCl, 0.1% Tween20) and blocked for 30 min at room temperature in Blocking Solution (0.5% Blocking Reagent, 10% sheep serum in TBS-T). Sheep anti-DIG antibody (Fab fragment, Roche) was diluted 1/2000 in Blocking Solution and incubated overnight at 4°C. After this, samples were washed in TBS-T and then in NTM buffer (0.1M Tris pH9.5, 0.1M NaCl, 0.05M MgCl2) and developed in NBT/BCIP solution (Roche) for 24 hrs.
  • TBS-T buffer 0.1M Tris pH9.5, 0.1M NaCl, 0.05M MgCl2
  • Muscle layer and sub-mucosa were carefully removed from human fresh rectal biopsy specimens, and mucosa was incubated with a mixture of antibiotics (Normocin, [Invivogen, San Diego, California 92121, USA], Gentamycin [Invitrogen, Carlsbad, CA,USA] and Fungizone [Invitrogen]) for 15 minutes at room temperature (RT).
  • antibiotics Normal, [Invivogen, San Diego, California 92121, USA]
  • Gentamycin Invitrogen, Carlsbad, CA,USA
  • Fungizone [Invitrogen] 15 minutes at room temperature (RT).
  • tissue was cut into small pieces and incubated with 10 mM Dithiotreitol (DTT) (Sigma, St. Louis, MO 63103, USA) in PBS 2-3 times for 5 minutes at RT. Samples were then transferred to 8 mM EDTA in PBS and slowly rotated for 60-75 minutes at 4°C.
  • DTT Dithiotreitol
  • Colony forming efficiency (%) was evaluated on freshly isolated crypts in order to exclude that the bioptic procedure and the isolation processing could have compromized their efficiency in forming mini-guts in in vitro culture.
  • DAPI staining was performed to confirm number of nuclei in freshly isolated crypts from CTRL and T1D+ESRD subjects.
  • Developed mini-guts with at least 1 crypt domain were also counted and percentage was calculated in order to add a more quantitative criteria to measure developed mini-guts ( Fig. 17 : A-P). Insulin and glucose levels measured on long-standing T1D (T1D+ESRD) and CTRL serum are reported below: Glucose levels (T1D+ESRD vs.
  • EphB2 APC anti-human EphB2 antibody, R&D, Minneapolis, MN
  • LGR5 PE anti-human LGR5, Origene, Rockville, MD
  • PI Propidium iodide
  • hTERT human-tert
  • Crypts were isolated from healthy subject rectal biopsy samples and cultured as previously described to generate mini-guts.
  • the culturing medium was modified by adding glucose at different concentrations (35 mM: high glucose; 5 mM: normal glucose).
  • human uremic serum obtained from long-standing T1D individuals with ESRD was added to crypts, which were cultured as reported in the crypt culturing methods section. After 8 days, crypts were collected, and the morphology, mini-gut growth, expression of intestinal signature markers (EphB2, LGR5, h-TERT), IGF-IR and TMEM219 (Life Technologies), and Caspase 9 (Life Technologies) were examined using RT-PCR.
  • a pan-caspase inhibitor (caspase inhibitor Z-VAD-FMK, 20 mM, Promega, Madison, WI), a Caspase 8 selective inhibitor (Z-IETD-FMK, BD Pharmingen), a Caspase 9 selective inhibitor (Z-LEHD-FMK, BD Pharmingen), a caspase3 inhibitor Z-DEVD-FMK (BD Pharmingen) were used in vitro in mini-guts to confirm the antiapoptotic effect of IGFBP3.
  • Total proteins of intestinal bioptic samples were extracted in Laemmli buffer (Tris-HCl 62.5 mmol/1, pH 6.8, 20% glycerol, 2% SDS, 5% ⁇ -mercaptoethanol) and their concentration was measured (Lowry et al., 1951). 35 ⁇ g of total protein was electrophoresed on 7% SDS-PAGE gels and blotted onto nitrocellulose (Schleicher & Schuell, Dassel, Germany). Blots were then stained with Ponceau S.
  • Laemmli buffer Tris-HCl 62.5 mmol/1, pH 6.8, 20% glycerol, 2% SDS, 5% ⁇ -mercaptoethanol
  • Membranes were blocked for 1 h in TBS (Tris [10 mmol/l], NaCl [150mmol/l]), 0.1% Tween-20, 5% non-fat dry milk, pH 7.4 at 25° C, incubated for 12 h with 200 mg/ml of a polyclonal anti-goat EphB2 antibody or polyclonal anti-goat LGR5 antibody (Santa Cruz Biotechnology, Santa Cruz, CA, USA) or monoclonal IGF-IR (Santa Cruz Biotechnology) and polyclonal TMEM219 (R&D, Minneapolis, MN) diluted 1:200 or with a monoclonal mouse anti- ⁇ -actin antibody (Santa Cruz Biotechnology) diluted 1:1000 in TBS-5% milk at 4° C, washed four times with TBS-0.1% Tween-20, then incubated with a peroxidase-labeled rabbit anti-goat IgG secondary antibody (or rabbit anti mouse for ⁇ -actin) diluted 1:1000 (
  • Live imaging of mini-guts obtained by purification and culture of intestinal crypts of CTRL, T1D+ESRD and SPK individuals, was performed on a Zeiss Axiovert S100 equipped with environmental control (from Oko-Lab, Italy) with a chamber in which a humidified premixed gas consisting of 5% CO 2 and 95% air was infused, and the whole setup was set at 37° C. Images were acquired at 20-minute intervals for 72 hours. Images were acquired and processed using Time Lapse (Oko-Lab, Italy) and, if necessary, image editing was performed using Adobe Photoshop Elements 7.0.
  • mini-guts were taken at day 0, 5 and 8 days by inverted microscopy Leica DH/RB and acquired with Axio Vision AC Release 4.3. Pictures reported in figures represent mini-guts at day 5, 10X magnification.
  • the inventors used the Human Stem Cell RT2 Profiler PCR Arrays (PAHS-405Z), the human Stem Cell Signaling PCR Array (PAHS-047Z,) and a custom array with the following genes: AXIN2, OLFM4, BMI1, RNF43, CDCA7, SLC12A2, CDK6, SOX9, DKC1, ZNRF3, ETS2, EPHB2, FAM84A, LGR5, GPX2, ACTB (SABiosciences).
  • the Profiler PCR Arrays measure quantitatively the expression of a panel of genes using SYBR Green-based real-time PCR (Kosinski et al., 2007).
  • RNA from purified intestinal crypts was extracted using Trizol Reagent (Invitrogen), and qRT-PCR analysis was performed using TaqMan assays (Life Technologies, Grand Island, NY) according to the manufacturer's instructions. The normalized expression values were determined using the ⁇ Ct method. Quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) data were normalized for the expression of ACTB, and ⁇ Ct values were calculated. Statistical analysis compared gene expression across all cell populations for each patient via one-way ANOVA followed by Bonferroni post-test for multiple comparisons between the population of interest and all other populations. Statistical analysis was performed also by using the software available RT 2 profiler PCR Array Data Analysis (Qiagen). For two groups comparison Student t test was employed.
  • Table I-B reports the main characteristics of primers used.
  • Table I-B Primers Gene Symbol UniGene # Refseq Accession # Band Size (bp) Reference Position LGR5 Hs.658889 NM_003667 91 1665 EPHB2 Hs.523329 NM_004442 68 2908 TERT Hs.492203 NM_198253 106 1072 ACTB Hs.520640 NM_001101 174 730 IGF-IR Hs.643120 NM_000875.3 64 2248 TMEM219 Hs.460574 NM_001083613.1 60 726 KRT20 Hs.84905 NM_019010.2 75 974 CHGA Hs.150793 NM_001275.3 115 521 EpcaM Hs.542050 NM_002354.2 95 784 LRP1 Hs.162757 NM_002332.2 64
  • IGF-I and IGFBP3 levels in the pooled sera/palsma of all groups of subjects and in all groups of treated and untreated mice was assessed using commercially available ELISA kits, according to the manufacturer's instructions (R&D and Sigma).
  • Human immortalized hepatoma cell line HuH-7 was cultured for 5 days in DMEM 10% FBS at different glucose concentrations: 5.5 mM, 20 mM and 35.5 mM. Culturing supernatant was collected, and IGFBP3 was assessed using an IGFBP3 ELISA kit (Sigma) according to the manufacturer's instructions. Collected cells were separated by trypsin and counted with a hemacytometer.
  • Insulin levels were assayed with a microparticle enzyme immunoassay (Mercodia Iso-Insulin ELISA) with intra- and inter-assay coefficients of variation (CVs) of 3.0% and 5.0%.
  • a microparticle enzyme immunoassay Mercodia Iso-Insulin ELISA
  • CVs intra- and inter-assay coefficients of variation
  • Recombinant human IGF-I (Sigma, 13769), (IGF-I), recombinant human IGFBP3 (Life Technologies, 10430H07H5), (IGFBP3), and anti-IGF-IR (Selleckchem, Boston, OSI-906) were added to crypt cultures at day +2 from isolation.
  • IGFBP3 (Reprokine, Valley Cottage, NY) was administered to naive and to STZ-treated B6 mice at 0.3 mg/mouse/day for 15 days; IGF-I (Reprokine) and ecto TMEM219 were administered in vivo to STZ-treated B6 mice after 2 weeks of diabetes at a dose of 5 ⁇ g/mouse/day for 20 days and 100 ⁇ g/mouse/day for 15 days respectively.
  • TMEM219 Recombinant human ecto-TMEM219 was generated using E. Coli as expression host for synthesis. Briefly, gene sequence of extracellular TMEM219 was obtained:
  • TMEM219 The DNA sequence of extracellular TMEM219 was cloned into a high copy-number plasmid containing the lac promoter, which is then transformed into the bacterium E. coli. Addition of IPTG (a lactose analog) activated the lac promoter and caused the bacteria to express extracellular TMEM219 (ecto TMEM219). SDS-PAGE and Western Blot were used to confirm purity higher than 90%. The molecular weight of the new generated protein recombinant human ecto TMEM219 was 80 kda.
  • Crypts from healthy subjects were isolated and cultured as previously described and ecto-TMEM219 was added to the culture at three concentrations (260 ng/ml, 130 ng/ml and 75 ng/ml) as compared to IGFBP3 concentration used (2:1, 1:1 and 1:2) and appropriate controls were set up for each concentration. After 8 days of culture, caspase 8 and 9 expression, CoSCSC signature markers (EphB2 and LGR5) expression, number of developed mini-guts, were further assessed.
  • Isolated crypts obtained from healthy subjects were grown to generate in vitro mini-guts in complete medium and in culturing medium modified by adding high glucose and long-standing T1D serum as previously described (see i n vitro mini-gut generation study in online methods).
  • 750 ng of small interfering RNA siRNA; Flexitube siRNA SI04381013, Qiagen, Valencia, CA
  • SiRNA small interfering RNA
  • HiPerFect Transfection Reagent Qiagen
  • Crypts were incubated with these transfection complexes under their normal growth conditions for 6h. Analysis of gene silencing was performed at 24, 48 and 72h by evaluating the percentage of normal mini-gut development. Control siRNA was used as a negative control to confirm the effect of gene silencing.
  • Mass spectrometry analysis was performed using an LTQ-Orbitrap mass spectrometer (Thermo Scientific, Waltham, MA) equipped with a nanoelectrospray ion source (Proxeon Biosystems). Full scan mass spectra were acquired with the lock-mass option and resolution set to 60,000.
  • the acquisition mass range for each sample was from m / z 300 to 1750 Da.
  • the ten most intense doubly and triply charged ions were selected and fragmented in the ion trap using a normalized collision energy 37%.
  • Target ions already selected for the MS/MS were dynamically excluded for 120 seconds. All MS/MS samples were analyzed using Mascot (v.2.2.07, Matrix Science, London, UK) search engine to search the UniProt_Human Complete Protcome_ cp_hum_2013_12. Searches were performed with trypsin specificity, two missed cleavages allowed, cysteine carbamidomethylation as fixed modification, acetylation at protein N-terminus, and oxidation of methionine as variable modification.
  • Mass tolerance was set to 5 ppm and 0.6 Da for precursor and fragment ions, respectively.
  • the raw data were loaded into the MaxQuant software version 1.3.0.5 (Cox et al., 2011). Label-free protein quantification was based on the intensities of precursors. Peptides and proteins were accepted with an FDR less than 1%, two minimum peptides per protein. The experiments were performed in technical triplicates.
  • the inventors first selected those with a more significant difference in LFQ intensity in comparing the two groups (p>0.005), leading to the exclusion of 12 factors ( Fig. 16 ).
  • the inventors evaluated whether altered factors may be associated with intestinal disorders and/or with the development of diabetes by searching for already reported studies and publications in the field. This led us to exclude other 12 factors.
  • the inventors ended up with 17 factors.
  • the inventors tested n 11 proteins in total.
  • mice C57BL/6 (B6) mice were obtained from the Jackson Laboratory, Bar Harbor, Maine. All mice were cared for and used in accordance with institutional guidelines approved by the Harvard Medical School Institutional Animal Care and Use Committee. Mice were rendered diabetic with streptozotocin injection (225 mg/kg, administered i.p.; Sigma). Diabetes was defined as blood glucose levels >250 mg/dL for 3 consecutive measures. Diabetic enteropathy was assessed as follows: briefly, the entire intestine was extracted from sacrificed mice and flushed with PBS. The extreme part of the colon was then cut and divided in two pieces. One piece of colon tissue was directly submerged in formalin while the other was cut longitudinally to expose the lumen and the internal mucosa and then submerged in formalin.
  • Tissue was then paraffin embedded and processed for H&E and immunostaining.
  • colonic tissue was also cut and isolation of colonic stem cells was performed as previously described (Merlos-Suarez et al., 2011). Briefly, colon was cut into 2-4 mm pieces and the fragments were washed in 30 mL ice-cold PBS. Fragments were the transferred in 50 ml tubes containing pre-warmed 20 mM EDTA-PBS and incubated at 37°C for 30 min. After incubation the suspended tissue was transferred into tube containing 30 ml cold PBS and centrifuged.
  • IGF-I ELISA kit R&D
  • IGFBP3 IGFBP3 ELISA kit, R&D
  • insulin levels Mercodia Mouse Insulin ELISA kit
  • the inventors first characterized intestinal morphology and function in a population of individuals with long-standing T1D and end stage renal disease (T1D+ESRD) and in healthy subjects (CTRL). Severe intestinal symptoms, such as diarrhea, abdominal pain and constipation, were evident in T1D+ESRD individuals as assessed using the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire ( Fig. 1 : A-C). Symptoms were associated with abnormalities in anorectal sphincter function ( Fig. 1 : D-F). The intestinal mucosa was altered in individuals with T1D+ESRD as compared to healthy subjects, with lower number of crypts, distortion and zonal sclerosis of the laminalitis ( Fig. 1 : G1-G2, H).
  • GSRS Gastrointestinal Symptom Rating Scale
  • Transcriptome profiling of crypts obtained from T1D+ESRD documented a decreased expression of Notch pathway (Notch1 and 2, JAG1, Dll1, Sox1 and 2), Wnt pathway (APC, FZD1, DKC1, ETS2, FAM84A, GPX2, RNF43) and BMP pathway (BMP1, BMP2, BMP3) genes, previously known pathways that control CoSCs, as compared to the expression of these genes in healthy subjects ( Fig. 8G and Table II).
  • Notch pathway Notch1 and 2, JAG1, Dll1, Sox1 and 2
  • Wnt pathway APC, FZD1, DKC1, ETS2, FAM84A, GPX2, RNF43
  • BMP1, BMP2, BMP3 BMP1, BMP2, BMP3
  • Down-regulated genes Up-regulated genes ACTC1 APC CD44 DVL1 BTRC SOX1 SOX2 WNT1 CCND2 FZD1 ADAR ACAN ALPI CD8A COL1A1 COL2A1 COL9A1 BMP1 BMP2 BMP3 CCNA2 CCNE1 CDC42 CDK1 CTNNA1 CXCL12 PARD6A CD3D CD8B MME CD4 DLL1 HDAC2 NOTCH1 DLL3 JAG1 NOTCH2 DTX2 KAT2A NUMB EP300 FGF2 FGF3 FGFR1 GDF3 ISL1 KRT15 MSX1 MYOD1 T GJA1 GJB1 GJB2 KAT8 RB1 h-TERT NCAM1 SIGMAR1 TUBB3 ABCG2 ALDH1A1 PDX1 IGF-I DHH BGLAP
  • the inventors used the in vitro mini-gut assay. Indeed, crypts isolated from T1D+ESRD individuals and cultured in vitro for 8 days formed small spheroid mini-guts that failed to grow as compared to healthy subjects ( Fig. 2 : J1, J2, K), despite a comparable viability ( Fig. 8 : H-I) and efficiency of forming mini-guts in both groups ( Fig. 8J ). To begin to elucidate the effect of circulating factors and high glucose on CoSCs, the inventors cultured isolated intestinal crypts obtained from healthy subjects in high glucose with/without serum obtained from long-standing T1D individuals in vitro for 8 days ( Fig.
  • Serum unbiased proteomic profiling revealed increased levels of IGFBP3 in long-standing T1D
  • the inventors compared the serum proteome of healthy subjects with T1D+ESRD individuals using an unbiased proteomic array. A clear proteomic profile was evident in T1D+ESRD individuals as compared to healthy subjects, with more than 50% of the detected proteins segregating in either one group or the other ( Fig. 3A ). Some proteins were associated with diabetes, and some were growth factors or stem cell-related proteins or were potentially involved in intestinal functions ( Fig. 3A ).
  • IGFBP2 and 3 the levels of IGF-I binding proteins (IGFBP2 and 3) were detectable in long-standing T1D individuals as compared to healthy subjects, with IGFBP3 almost 5-fold increased ( Fig. 3B ), while IGFBP1, 4, 5 and 6 remained almost undetectable.
  • IGFBP3 immunohistochemical expression as compared to healthy subjects ( Fig. 3 : C1-C2, Fig. 8 : K, L1-L6), suggesting an increase in IGFBP3 hepatic synthesis and release.
  • IGF-IR and of IGFBP3 receptor TMEM219
  • isolated crypts Fig. 3 : F, H, Fig. 8 : M, N1-N2
  • WB Fig. 3 : F, H, Fig. 8M
  • IGF-I and IGFBP3 In order to mechanistically confirm the role of IGF-I and IGFBP3 on CoSC, the inventors tested the effect of several molecules, identified by proteomic profiling, in their in vitro mini-gut assay. Inventors' strategy to select potential targets is reported in Supplemental Information. The severely altered mini-guts generated from intestinal samples obtained from T1D+ESRD individuals were rescued by the addition of recombinant human IGF-I (IGF-I) to the culture medium ( Fig. 31 ), while the addition of recombinant human IGFBP3 (IGFBP3) resulted in the abrogation of the positive effect observed with IGF-I, with a decreased development of mini-guts and increased formation of collapsed and distorted organoids ( Fig. 31 ).
  • IGF-I recombinant human IGF-I
  • IGFBP3 recombinant human IGFBP3
  • IGFBP3 has been recently shown to act independently of IGF-I (Williams et al., 2007) via the IGFBP3 receptor (TMEM219)(Baxter, 2013), it was necessary to clarify whether IGFBP3 exerts its effects on CoSCs by binding IGF-I or by directly targeting TMEM219 on CoSCs.
  • the inventors first confirmed that IGFBP3 has a direct pro apoptotic effect on CoSCs by demonstrating increased Caspase 8 and 9 expression in mini-guts obtained from healthy subjects and long-standing T1D individuals and cultured with IGFBP3 ( Fig. 3J , Fig.
  • TMEM219 expression by using siRNA in vitro in mini-guts obtained from healthy subjects. Knockdown of TMEM219 in mini-guts preserved their ability to grow and self-renew, despite the addition of IGFBP3 and high glucose with long-standing T1D serum ( Fig. 3M ). Concomitant blockade of TMEM219 by SiRNA and IGF-IR by blocking antibody did not result in any additional beneficial effect on mini-guts development despite using serum from healthy subjects or from long-standing T1D ( Fig. 9E ).
  • circulating proteins which appeared altered in serum proteome of long-standing T1D individuals, were tested in the in vitro mini-gut assay and did not show any significant effect on mini-guts growth ( Fig. 9 : F-G).
  • C-peptide and insulin whose levels are commonly altered in T1D and which may interfere with IGF-I/IGFBP3 dyad by binding IGF-IR ( Fig. 9H ), were tested as well and did not show any effect.
  • the inventors flow sorted EphB2 + cells from isolated crypts and established that TMEM219 was highly expressed on their surface ( Fig. 4A ).
  • the inventors then cultured EphB2 + cells in the in vitro single cell-derived mini-gut assay and confirmed that high glucose and long-standing T1D serum exposure as well as addition of IGFBP3 significantly abrogate single cell-derived mini-guts growth, thus recapitulating the main features reported in their previous observations on crypt-derived mini-guts ( Fig. 4B , Fig. 10 : A1-A3).
  • IGF-I/IGFBP3 dyad on pathways previously known to be involved in CoSC niche function (i.e. Wnt/Notch/BMP)
  • the inventors obtained from their stem cell transcriptome profile the expression of niche specific gene transcripts.
  • IGF-I restores significantly the expression of some factors associated with Wnt/Notch signaling pathways on mini-guts obtained from crypts of T1D+ESRD ( Fig. 10E , Table III), while IGFBP3 poorly affects Wnt/Notch/BMP gene expression in mini-guts obtained from crypts of healthy subjects or from those of T1D+ESRD ( Fig. 10F , Table III).
  • Table III Table III.
  • CTRL CD8B COL9A1, RB1, SOX1, h-TERT ASCL2, COL2A1, DHH, DLL1, DTX1, DVL1, FGF3, FGF4, FOXA2, FRAT1, GDF2, HSPA9, IGF1, KAT2A, MSX1, MYC, NEUROG2, S100B, WNT1 TID+ESRD+IGF-I vs.
  • T1D+ESRD ABCG2 ALDHlA1, ALPI, CD3D, CD4, CD44, CD8A, CDC42, FGF2, FGFR1, JAG1, SIGMAR1, SOX1, TUBB ASCL2, KAT2A, MYC, NCAM1, NEUROG2, SOX2 Abbreviations: IGF-I, insulin-like growth factor 1; IGFBP3, insulin-like grwth factor binding protein 3, CTRL, healthy subjects, T1D, type 1 diabetes, ESRD, end-stage renal disease.
  • IGF-I preserves the expression of some genes involved in Wnt/Notch/BMP signaling, but also that IGFBP3 acts independently on CoSCs, without major alterations in the expression of key-target genes of the other previously known pathways.
  • T1D+ESRD freshly isolated colonic crypts and in those cultured with IGFBP3 and IGF-I (at least p ⁇ 0.05).
  • Down-regulated genes Up-regulated genes TID+ESRD vs. CTRL BCL2, NOL3, FAS CASP1, CASP10, CASP14, CASP5, CASP6, CASP7, CASP8, CASP9, CD27, CRADD, FADD, FASLG, HRK, TNFRSF10A, TNFRSF10B, TNFRSF11B, TNFRSF1A, TNFRSF1B, TNFRSF25, TNFRSF9, TNFSF8, TRADD, TRAF3 CTRL+ IGF-I vs.
  • T1D+ESRD BAX BCL2, NOL3, TNFRSF1B CASP9, CD27
  • IGF-I insulin-like growth factor 1
  • IGFBP3 insulin-like grwth factor binding protein 3
  • CTRL healthy subjects
  • T1D type 1 diabetes
  • ESRD end-stage renal disease.
  • T1D+ESRD CYBB DUOX1, EPHX2 GPX3, GSTP1, HSPA1A MGST3, NCF1, NQO1, PRDX6, RNF7, TXN NOS2, STK25
  • IGF-I insulin-like growth factor 1
  • IGFBP3, insulin-like grwth factor binding protein 3, CTRL healthy subjects
  • T1D type 1 diabetes
  • ESRD end-stage renal disease.
  • mice showed increased serum levels of IGFBP3 and low levels of IGF-I, with lower murine insulin levels as compared to naive B6 ( FIG. 11 : A-C).
  • Intraperitoneal (i.p.) administration of IGFBP3 in naive B6 mice resulted in a reduction in local crypt numbers ( Fig. 4 : F, H3), with the majority of crypts showing increased depth and width ( Fig. 4 : G, H3, I) and significant reduction in Aldh + cells as compared to untreated mice ( Fig. 4 : J, K3).
  • Fig. 4 J, K3
  • Transcriptome analysis revealed that SPK nearly restored the expression of stem cell and CoSC markers and of pathways involved in preserving CoSCs ( Fig. 5I , Fig. 13B , Table VII).
  • Table VII List of up and down-regulated stem cell target genes identified by transcriptomic profiling in SPK as compared to T1D+ESRD freshly isolated colonic crypts (at least p ⁇ 0.05).
  • Up-regulated genes Up-regulated genes DVL1 ACTC1 APC CCND2 WNT1 BTRC SOX1 SOX2 ACAN COL1A1 COL2A1 BMP3 CCNE1 CDK1 CXCL2 CD8B MME DLL3 HDAC2 JAG1 DTX2 FGF2 GDF3 ISL1 MSX1 MYO1 GJA1 RB1 h-TERT NCA1 SIGMAR1 PDX1 DHH BGLA P
  • EGF epithelial growth factor
  • FGF fibroblast growth factor
  • BMP bone morphogenetic protein
  • the ecto-TMEM219 recombinant protein abrogates IGFBP3-mediated mini-gut destruction in vitro and preserves CoSCs in vivo in a murine model of DE.
  • the inventors generated a recombinant protein based on the TMEM219 extracellular domain (ecto-TMEM219).
  • ecto-TMEM219 (2:1 molar ratio with IGFBP3)
  • IGFBP3 a recombinant protein based on the TMEM219 extracellular domain
  • CoSC signature markers EphB2 and LGR5
  • IGFBP3 and ecto-TMEM219 The expression of CoSC signature markers, EphB2 and LGR5, significantly recovered in mini-guts cultured with IGFBP3 and ecto-TMEM219, emphasizing a favorable effect in preserving CoSCs ( Fig. 6B ), which was also confirmed in high glucose-cultured mini-guts ( Fig. 6A ).
  • Analysis of Caspase 8 and 9 by RT-PCR documented a net decrease in their expression when ecto-TMEM219 was added to IGFBP3-cultured mini-guts as compared to IGFBP3 alone ( Fig. 6 : C-D).
  • the inventors then treated STZ-B6 mice with ecto-TMEM219 and observed improved mucosa morphology with recovered number, depth and width of crypts ( Fig. 6 : E, F, G).
  • Administration of ecto-TMEM219 was associated with an increase in mice body weight as compared to STZ-treated B6 ( Fig. 6H ), with significant regain of CoSCs ( Fig. 6 : I-K), a decreased expression of caspase 8 and 9 ( Fig. 6 : L-M) and a re-establishment of circulating IGFBP3 levels ( Fig. 6N ).
  • Diabetic enteropathy represents a clinically relevant complication in individuals with T1D, as it is associated with lower quality of life, malnutrition and malabsorbtion (Bytzer et al., 2002; Faraj et al., 2007; Talley et al., 2001).
  • T1D+ESRD intestinal disorders occur with high frequency and severity (Cano et al., 2007; Wu et al., 2004), resulting in body mass loss and cachexia (Pupim et al., 2005), indicating that enteropathy is an important complication of long-standing T1D (Atkinson et al., 2013; Pambianco et al., 2006).
  • T1D+ESRD vs. CTRL SKP vs. T1D+ESRD, K+T1D vs. SKP.
  • T1D type 1 diabetes
  • ESRD end stage renal disease
  • CTRL healthy subjects
  • SPK simultaneous kidney-pancreas transplantation.
  • IGF-I acts as a circulating enterotrophic factor that promotes crypt growth and controls CoSCs through IGF-IR
  • IGFBP3 can block IGF-I signaling by binding circulating IGF-I and reducing its bioavailability.
  • IGFBP3 acts through a pro-apoptotic IGF-I-independent mechanism on CoSCs, which the inventors demonstrated express TMEM219 (the IGFBP3 receptor), thereby inducing the failure of mini-gut growth.
  • T1D together with starvation and cachexia are characterized by low circulating IGF-I levels (Bondy et al., 1994; Giustina et al., 2014) due to reduced hepatic IGF-I release, which is controlled and stimulated by endogenous insulin (Le Roith, 1997; Sridhar and Goodwin, 2009). More importantly, hyperglycemia appeared to have a direct effect on hepatic synthesis and release of IGFBP3.
  • IGFBP3 may thus act as a hepatic hormone that reduces intestinal absorptive capacity during hyperglycemia.
  • SPK provided a proof of concept to the inventors' hypothesis and supported their findings regarding the existence of circulating factors that control CoSCs.
  • the newly generated ecto-TMEM219 recombinant protein improved DE in diabetic mice in vivo and restored the ability of mini-guts to grow normally in vitro, thus confirming the role of IGFBP3 in controlling CoSCs and paving the way for a novel potential therapeutic strategy.
  • IGFBP3-mediated disruption of CoSCs linked to hyperglycemia is evident in DE.
  • the inventors suggest that circulating IGF-I/IGFBP3 represent a hormonal dyad that controls CoSCs and a novel therapeutic target for individuals with intestinal disorders, in particular caused by diabetes mellitus of long duration (Bondy et al., 1994; Bortvedt and Lund, 2012; Boucher et al., 2010).
  • T1D+ESRD 60 individuals with T1D+ESRD registered on the waiting list for simultaneous pancreas-kidney transplantation (SPK) matched for (age 41 to 43 years old), gender, and duration of T1D (29.4 ⁇ 1.8 years) were enrolled in the study.
  • T1D+ESRD subjects were all on intensive insulin treatment at the time of enrollment in the study, while the CTRL group was not being administered any medication.
  • T1D+ESRD subjects were on the same treatment as antiplatelet therapy (ASA) and anti-hypertension (angiotensin-converting-enzyme inhibitors), while 40 out of 60 received statins when enrolled in the study. Subjects with clear signs of inflammatory bowel diseases as well as celiac disease were not enrolled.
  • ASA antiplatelet therapy
  • anti-hypertension angiotensin-converting-enzyme inhibitors
  • Individuals taking an oral anticoagulant agent were not included.
  • SPK individuals were all insulin-independent for the entire follow-up period, whereas K+T1D individuals were on intensive subcutaneous insulin therapy. All subjects provided informed consent before study enrollment. Studies not included in the routine clinical follow-up were covered by an appropriate Institutional Review Board approval (Enteropatia-trapianto/01 Secchi/Fiorina).
  • Serum was collected from 3 ml of fresh blood after centrifugation. Urine samples were collected fresh, centrifuged and stored at -80°C. IGFBP3 levels of all groups of subjects were assessed in frozen samples of serum and urine using commercially available ELISA kits, according to the manufacturer's instructions (R&D).
  • Correlation analysis and graphs were performed using Prism Graphpad software. Correlation analysis included assessment of IGFBP3 levels in serum vs. urine of individuals evaluated, IGFBP3 serum levels vs. estimated glomerular filtration rate (eGFR). Statistical significance was considered when p value was ⁇ 0.05.
  • MDRD formula was used to assess estimated glomerular filtration rate (eGFR) in ml/min/m2. Blood tests included assessment of Creatinine, blood glucose, glycated hemoglobin in all subjects enrolled in the study focusing on comparing CTRL with T1D individuals and individuals with longstanding T1D (T1D+ESRD).
  • the inventors can also identify a normal range of urinary IGFBP3 levels ( ⁇ 350 pg/ml) by considering its correlation with serum IGFBP3 levels as represented in the gray area in Figure 7F .
  • IBD inflammatory bowel disease
  • an inhibitor of IGFBP3 is also beneficial for the treatment and/or prevention of inflammatory bowel diseases.
  • T1D Sixty serum samples from individuals with type 1 (T1D), with T1D of long (> 15 years) duration (long-standing T1D) and healthy volunteers (CTRL) matched for age and gender were obtained from blood collection at the San Raffaele Hospital. Twenty serum samples from individuals screened positive for islets Autoantibodies test were collected at the collaborating site of Gainsville (Florida). 235, 200 and 81 serum samples from normal glucose tolerant (NGT), impaired glucose tolerant (IGT) and type 2 diabetes (T2D) individuals were collected from University of Pisa (Italy) under the Genfiev protocol study. NGT, IGT, and T2D were determined based on the results of OGTT test according to the ADA 2003 criteria.
  • NGT normal glucose tolerant
  • IGT impaired glucose tolerant
  • T2D type 2 diabetes
  • the human islets used in this study were isolated from cadaveric organ donors according to the procedure already described (Petrelli et al., 2011) in conformity to the ethical requirements approved by the Niguarda Cà Granda Ethics Board. Briefly, islets were isolated using the automated method already described (D'Addio et al., 2014). Two types of enzymes were used: collagenase type P (1-3 mg/ml) and liberase (0.5-1.4 mg/ml) (Roche, Indianapolis, IN, USA).
  • Islets were purified by discontinuous gradient in syringes (density gradient: 1,108; 1,096; 1,037: Euroficoll, (Sigma-Aldrich, Milan, Italy), or by continuous gradient with refrigerated COBE processor as previously described (Nano et al., 2005).
  • islets were cultured at 22°C in a humidified atmosphere (5% CO 2 ), in M199 medium (Euroclone, Celbio, Milan, Italy) or CMRL (Mediatech, Cellgro, VA, USA) supplemented with 10% FCS, 100 U/ml penicillin, 100 ⁇ g/ml streptomycin sulphate (Euroclone, Celbio) and 2 mmol/l glutamine (Mediatech, Cellgro, VA, USA).
  • M199 medium Euroclone, Celbio, Milan, Italy
  • CMRL Mediatech, Cellgro, VA, USA
  • FCS 100 U/ml penicillin
  • streptomycin sulphate Euroclone, Celbio
  • 2 mmol/l glutamine Mediatech, Cellgro, VA, USA
  • Islets were cultured in CMRL 10% FCS, supplemented with 100 ⁇ g/ml streptomycin sulphate (Euroclone, Celbio) and 2 mmol/l glutamine (Mediatech, Cellgro, VA, USA) with a glucose concentration of 5 mM for 4 days.
  • Murine islets were kindly provided by Prof. James Markmann (Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston) (Ben Nasr et al., 2015b; Vergani et al., 2010). Pancreatic islets were isolated from C57B16/J mice by collagenase digestion followed by density gradient separation and then hand-picking, as described previously(Forbes et al., 2010). Islets were then plated and cultured in RPMI 1640 medium supplemented with L-glutamine, penicillin and 10% as already described, with a glucose concentration of 5 mM for 4 days.
  • ⁇ TC3 and ⁇ TC1 cells were kindly provided by Carla Perego, University of Milan, with the permission of Prof. Douglas Hanahan (Department of Biochemistry and Biophysics, University of California, San Francisco, CA)(Di Cairano et al., 2011).
  • ⁇ TC3 were cultured in RPMI 1640 medium (Sigma) containing 0.1 mM glutamic acid and supplemented with 0.7 mM glutamine as described (Di Cairano et al., 2011). The glucose concentration was 11 mM for cell lines.
  • insulin Dako, A0564
  • anti-IGFBP3 primary antibody polyclonal, 1:50 dilution, Sigma Aldrich HPA013357
  • anti-TMEM219 primary antibody polyclonal, 1:100, Sigma HPA059185.
  • These antibodies were immunohistochemically tested in pancreatic tissues of healthy subjects, B6 and NOD mice and in liver biopsies of patients with T1D/T2D, islet transplanted patients who did not achieve insulin independence. Tissues without pathological findings were used as controls. All of these tissue samples came from the files stored at the Unit of Pathology of the Department of Biomedical, Biotechnological, and Translational Sciences, University of Parma, Parma, Italy.
  • the immunostaining intensity was graded as 1 (mild), 2 (moderate), and 3 (strong), while its diffusion as 1 (focal), 2 (zonal), and 3 (diffuse).
  • Immunofluorescence samples were observed using a confocal system (Leica TCS SP2 Laser Scanning Confocal). Images were acquired in multitrack mode, using consecutive and independent optical pathways. The following primary antibodies were used for staining of human tissues/cells: mouse monoclonal anti-caspase cleavage product of cytokeratin 18 M30 (clone M30, Hoffmann-LaRoche, Basel, Switzerland), rabbit polyclonal IGFBP3 (1:250, Sigma, HPA013357), rabbit polyclonal TMEM219 (1:250, Sigma, HPA059185) and Guinea Pig polyclonal insulin (1:50, DAKO, A0564).
  • the following primary antibodies were used for staining of murine tissues/cells: rabbit polyclonal IGFBP3 (1:250, Sigma, SAB4501527), goat polyclonal TMEM219 (1: 50, Santa Cruz, 244405), Guinea Pig polyclonal insulin (1:50, DAKO, A0564).
  • the following secondary antibodies were used for staining of human tissues/cells: donkey anti-rabbit FITC (Jackson) and donkey anti-guinea pig TRITC (Jackson).
  • the following antibody was used for staining of murine tissues/cells: donkey anti-goat FITC (Jackson).
  • Murine beta cells co-cultured in the same conditions as pancreatic islets were fixed in 10% neutral buffered for 30 min, washed with PBS three times and permeabilized with PBS - BSA 2 % triton x100 0.3 % for 20 min, blocked with serum 10 %, and finally incubated with primary antibodies over-night at 4°C and subsequently labeled with fluorescent secondary antibodies for 2 hour at room temperature.
  • Primary and secondary antibodies were selected as described above.
  • Human and murine islets were cultured at different glucose concentration (5mM, 20mM, Sigma), with/without inflammatory stimuli/cocktail (IFN- ⁇ + IL-1 ⁇ , 2 ng/ml R&D Systems and 1,000 U/ml Peprotech, respectively), with/without IGFBP3 (Life Technologies, 50 ng/ml), with/without ecto-TMEM219 (130 ng/ml, see Recombinant proteins and interventional studies ) and islets were collected for immunofluorescence studies, RNA extraction, apoptosis detection, and protein analysis. Supernatants were collected for assessment of insulin, IGFBP3 and IGF-I secretion.
  • ⁇ -TC were cultured as previously described, with/without inflammatory stimuli/cocktail (IFN- ⁇ + IL-1 ⁇ ), with/without IGFBP3, with/without ecto-TMEM219 (see Recombinant proteins and interventional studies ) and cells were collected as for islets studies.
  • Total proteins of intestinal bioptic samples were extracted in Laemmli buffer (Tris-HCl 62.5 mmol/1, pH 6.8, 20% glycerol, 2% SDS, 5% b-mercaptoethanol) and their concentration was measured. 35 mg of total protein was electrophoresed on 7% SDS-PAGE gels and blotted onto nitrocellulose (Schleicher & Schuell, Dassel, Germany). Blots were then stained with Ponceau S.
  • Membranes were blocked for 1 h in TBS (Tris [10 mmol/1], NaCl [150mmol/l]), 0.1% Tween-20, 5% non-fat dry milk, pH 7.4 at 25° C, incubated for 12 h with a rabbit polyclonal IGFBP3 antibody (Sigma, HPA013357) diluted 1:250, or goat polyclonal TMEM219 (Santa Cruz Biotechnology, 244404 or 244405) diluted 1:200 or with a monoclonal mouse anti-b-actin antibody (Santa Cruz Biotechnology) diluted 1:500 in TBS-5% milk at 4° C, washed four times with TBS-0.1% Tween-20, then incubated with a peroxidase-labeled mouse anti-rabbit IgG secondary antibody (DAKO) (for IGFBP3) or rabbit anti-goat (for TMEM219) or rabbit anti mouse for b-actin, diluted 1:1000 (Santa Cruz Biotechnology) in TBS-
  • RNA from purified intestinal crypts was extracted using Trizol Reagent (Invitrogen), and qRT-PCR analysis was performed using TaqMan assays (Life Technologies, Grand Island, NY) according to the manufacturer's instructions. The normalized expression values were determined using the ⁇ Ct method. Quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) data were normalized for the expression of ACTB, and ⁇ Ct values were calculated. Statistical analysis compared gene expression across all cell populations for each patient via one-way ANOVA followed by Bonferroni post-test for multiple comparisons between the population of interest and all other populations. Statistical analysis was performed also by using the software available RT 2 profiler PCR Array Data Analysis (Qiagen). For two groups comparison Student t test was employed.
  • IGF-I and IGFBP3 levels in the pooled sera/plasma of all groups of subjects and in all groups of treated and untreated mice were assessed using commercially available ELISA kits, according to the manufacturer's instructions (R&D SG300, and Sigma RAB0235).
  • HEP10TM Human primary hepatocytes (HEP10TM Pooled Human Hepatocytes, ThermoFisher Scientific) were cultured for 3 days in Williams Medium as per manufacturer's instructions at different glucose concentrations: 11 mM, 20 mM and 35 mM. Culturing supernatant was collected, and IGFBP3 was assessed using an IGFBP3 ELISA kit (Sigma, RAB0235) according to the manufacturer's instructions. Collected cells were separated by trypsin and counted with a hemacytometer.
  • Insulin levels were assayed with a microparticle enzyme immunoassay (Mercodia Iso-Insulin ELISA, 10-1113-01) with intra- and inter-assay coefficients of variation (CVs) of 3.0% and 5.0%.
  • a microparticle enzyme immunoassay Mercodia Iso-Insulin ELISA, 10-1113-01
  • CVs intra- and inter-assay coefficients of variation
  • Recombinant human IGF-I (Sigma, 13769), 100 ng/ml (IGF-I), recombinant human IGFBP3 (Life Technologies, 10430H07H5), 50 ng/ml (IGFBP3), anti-IGF-IR (Selleckchem, Boston, OSI-906), 1 ⁇ M/L and ecto-TMEM219(D'Addio et al., 2015), 130 ng/ml were added to islets/cell cultures at day +1 from islets collection/cell culture.
  • Pancreatic islets and beta cells were also exposed to complex diabetogenic conditions: 20 mM glucose, the mixture of 2 ng/ml recombinant human IL-1 ⁇ (R&D Systems, Minneapolis, MN 201-LB-005), and 1,000 U/ml recombinant human IFN- ⁇ (PeProTech, 300-02) for 72h.
  • IGFBP3 (Reprokine, Valley Cottage, NY) was administered to naive B6 mice at 150 ⁇ g /mouse/day for 15 days intraperitoneally (i.p.); ecto-TMEM219 was administered in vivo to STZ-treated B6, to 10 weeks old NOD and to B6 fed a high fat diet (HFD-B6) mice intraperitoneally (i.p.) at a dose of 150 ⁇ g/mouse/day for 15 days in STZ-treated B6 and in NOD, and 100 ⁇ g/mouse every other day for 8 weeks in HFD-B6 mice.
  • HFD-B6 mice high fat diet mice
  • mice Male C57BL/6 (B6) mice and female non-obese diabetic (NOD) mice (4 weeks old and 10 weeks old) were obtained from the Jackson Laboratory, Bar Harbor, Maine. All mice were cared for and used in accordance with institutional guidelines approved by the Harvard Medical School Institutional Animal Care and Use Committee. B6 mice were rendered diabetic using a chemical approach with streptozotocin (STZ) injection (225 mg/kg, administered i.p.; Sigma S0130) this model is accepted and validated as a model of T1D diabetes (Carvello et al., 2012; Petrelli et al., 2011; Vergani et al., 2013). Diabetes was defined in both STZ-treated B6 and NOD as blood glucose levels >250 mg/dL for 3 consecutive measures.
  • STZ streptozotocin
  • mice (6 weeks old) were housed in a germfree Animal house in accordance with the Principles of Laboratory Animal Care (NIH Publication No 85-23, revised 1985) and received water and food ad libitum. The study protocol was approved by the local ethics committee. Mice were fed with either a High Fat Diet (HFD) (DIO diet D12492, 60% of total calories from fat) or a normal-fat diet (NFD; DIO diet D12450B; 10% of total calories from fat), purchased from Research Diets (Mucedola, Settimo Milanese, Italy). Each group of treatment or control consisted of 10 animals.
  • HFD High Fat Diet
  • NFD normal-fat diet
  • mice After 16 weeks, glycemia was measured and IV glucose tolerance test (IVGTT) was performed. The next day, mice were anaesthetized and then a blood sample was obtained and pancreas was harvested for histology studies. A portion of the tissue was also snap-frozen and stored in Trizol to perform RT-PCR studies.
  • IVGTT IV glucose tolerance test
  • IGF-I ELISA kit R&D MG100
  • IGFBP3 IGFBP3 ELISA kit, R&D MGB300
  • insulin levels Me Insulin ELISA kit, Mercodia, 10-1247-01. Blood glucose was monitored twice per week up to 12 weeks in HFD-B6 in order to confirm diabetes onset and permanence.
  • IGFBP3 peripheral levels are increased in pre-diabetic and diabetic mice.
  • the inventors profiled the serum proteome of healthy subjects and individuals at risk for T1D, based on the presence of one or more anti-islets autoantibodies, using an unbiased proteomic approach. Proteins, which were significantly different (p-value ⁇ 0.01) in control pool versus individuals at risk for T1D pool, were further submitted to hierarchical clustering analysis. A clear proteomic profile was evident in individuals at risk for T1D (and in overtly T1D as well) as compared to healthy subjects, with more than 50% of the detected proteins segregating in either one group or the other.
  • IGFBP3 IGF-I binding proteins 3
  • NGT normal glucose tolerant
  • IGFT impaired glucose tolerant
  • T2D T2D
  • IGFBP3 Increased IGFBP3 production by hepatocytes in inflamed environment and in T1D.
  • Liver is known to be a site of IGFBP3 production.
  • IGFBP3 inflammatory stimuli could influence hepatic IGFBP3 production
  • the inventors cultured human primary hepatocytes with various cytokines and with different glucose concentrations (11, 20 and 35 mM) and demonstrated that IGFBP3 levels in the supernatants increased rapidly following different pro-inflammatory stimuli and increased glucose levels ( Fig. 21 : A-B).
  • TMEM219 is expressed in human islets.
  • TMEM219 expression was assessed by using immuno fluorescence and its co-localization with insulin at the confocal microscopy ( Fig. 22 : A1-A2).
  • Human islets obtained from cadaver donors whose pancreas were not suitable for organ donation were studied.
  • TMEM219 green staining
  • Fig. 22 : A1-A2 The inventors further evaluated the expression of the other known receptors for IGFBP3 (i.e. LPR1, TGF- ⁇ R1 and TGF- ⁇ R2) but none appeared expressed ( Fig. 22B ).
  • the inventors confirmed TMEM219 expression by using RT-PCR and WB ( Fig. 22 : B-C).
  • TMEM219 in murine islets using RT-PCR and excluded that of other known IGFBP3 receptors (LRP1, TGF-beta type 1 and TGF-beta type 2) already described in other cells and models (Baxter, 2013; Forbes et al., 2010) ( Fig. 23A ).
  • LRP1, TGF-beta type 1 and TGF-beta type 2 already described in other cells and models (Baxter, 2013; Forbes et al., 2010) ( Fig. 23A ).
  • the inventors made use of the availability of murine beta and alpha cell lines ( ⁇ TC and ⁇ TC), and determined by RT-PCR that expression of TMEM219 is restricted to beta cells while other islet cells, such as alpha cells, do not express it ( Fig. 23B ) and further confirm TMEM219 expression by WB ( Fig. 23C ).
  • Immunofluorescence staining of TMEM219 (green) and its co-localization with insulin was also
  • IGFBP3 damages a beta cell line in vitro.
  • IGFBP3 targets beta cells within the islets
  • the inventors cultured a beta cell line ( ⁇ TC) for 3 days with/without IGFBP3.
  • ⁇ TC beta cell line
  • the inventors were able to demonstrate a reduced percentage of viable beta cells in IGFBP3-treated conditions as compared to untreated ( Fig. 24A ).
  • IGFBP3-treated beta cells also showed a significant increase in caspase8 expression ( Fig. 24B ) and a reduction in insulin expression by both immunofluorescence and RT-PCR ( Fig. 24 : C, D1-D2, E).
  • IGFBP3-induced apoptosis was markedly higher than that induced by the pro-inflammatory stimuli IL-1 ⁇ and IFN- ⁇ ( Fig. 24 : A-B) and insulin expression and release were only slightly reduced ( Fig. 24 : C-E).
  • IGFBP3 damages murine islets in vitro.
  • IGFBP3-mediated detrimental effect on islets the inventors cultured murine islets isolated from C57BL/6 mice for 4 days with/without IGFBP3.
  • the appearance of extensive apoptosis as assessed by FACS (Annexin V + 7AAD - ) documented that IGFBP3-treated islets undergo early apoptosis (87 ⁇ 2 vs. 67 ⁇ 2%, p 0.004), associated with an increase in caspase 8 expression and with a decrease in insulin expression by RT-PCR ( Fig. 25 : A-C).
  • IGFBP3 damages human islets in vitro.
  • the inventors finally confirmed the IGFBP3-mediated detrimental effects in human islets by demonstrating that in vitro cultured human islets, obtained from cadaver donors whose pancreata were not suitable for organ donation, exposed to IGFBP3 for 4 days underwent greatly to apoptosis ( Fig. 26A ), showed an increase in caspase 8 expression ( Fig. 26B ) and an increased expression of M30 ( Fig. 8 : C1-C2), a marker for apoptosis, associated with a decrease in insulin expression at immunostaining ( Fig. 26 :D1-D2) and using RT-PCR ( Fig.26E ).
  • IGFBP3 injection in C57BL / 6 mice alters islet morphology in vivo.
  • IGFBP3 alters islet morphology
  • the inventors injected recombinant IGFBP3 (Reprokine) in na ⁇ ve B6 and STZ-treated B6 mice (150 ⁇ g every day for 15 days). Histology (H&E) analysis of collected pancreata demonstrated an increased derangement in islets of STZ-B6 IGFBP3-treated mice as compared to islets of na ⁇ ve and STZ-B6 mice, confirmed by scattered insulin expression upon immunostaining ( Fig. 27 : A1-A6).
  • the recombinant protein ecto-TMEM219 prevents IGFBP3-associated damage in a beta cell line in vitro.
  • ecto-TMEM219 prevents IGFBP3-associated detrimental effects specifically on beta cells
  • the inventors cultured a beta cell line with IGFBP3 and ecto-TMEM219 and observed that beta cell apoptosis was greatly reduced by the addition of ecto-TMEM219.
  • the effect was also confirmed by the analysis of caspase 8 expression which appeared reduced in IGFBP3+ecto-TMEM219-treated beta cells as compared to those cultured with IGFBP3 only ( Fig. 28 : A-B). Insulin expression, as assessed by RT-PCR and immunofluorescence (red), was consistently increased by the addition of ecto-TMEM219 to IGFBP3-cultured beta cells ( Fig. 28 : C1-C3).
  • ecto-TMEM219 In order to further confirm the therapeutic properties of ecto-TMEM219 in preventing IGFBP3-associated damage, the inventors tested the effect of ecto-TMEM219 in cultured murine islet in vitro.
  • the addition of ecto-TMEM219 (2:1 molar ratio with IGFBP3) to isolated C57BL/6 islets co-cultured with IGFBP3 abrogated the pro-apoptotic effect of IGFBP3.
  • caspase 8 expression was significantly reduced in islets cultured with IGFBP3 and ecto-TMEM219 ( Fig. 29A ).
  • Insulin expression was increased by the addition of ecto-TMEM219 to murine islets cultured with IGFBP3 ( Fig. 29B ), emphasizing a favorable effect of ecto-TMEM219 on preserving islet function.
  • the recombinant protein ecto TMEM219 prevents IGFBP3-associated islet alterations.
  • ecto-TMEM219 In order to prove the effect of ecto-TMEM219 in the treatment of diabetes, the inventors measured insulin serum levels in STZ-treated diabetic mice at 8 weeks and observed that insulin was significantly increased in those mice that were treated with ecto-TMEM219 (i.p. 150 ⁇ g every other day for 2 weeks) as compared to untreated STZ-B6 ( Fig. 31A ). Finally, in another model of islet injury in vivo, B6 mice fed with a high fat diet (B6-HFD) showed altered blood glucose and insulin levels, while B6-HFD treated with ecto-TMEM219 (i.p. 100 ⁇ g every other day for 6 weeks) maintained near-normal glucose and insulin levels ( Fig. 31B ), thus suggesting a curative effect of ecto-TMEM219 in type-1 and type-2 diabetes.
  • B6-HFD high fat diet
  • Type 1 diabetes has historically been regarded as a T cell-mediated autoimmune disease, resulting in the destruction of insulin-producing pancreatic beta cells (Bluestone et al., 2010; Eisenbarth, 1986). According to this perspective, an initiating factor triggers the immune response against autoantigens, and the subsequent newly activated autoreactive T cells target and further destroy insulin-producing beta cells (Bluestone et al., 2010). Whether destruction of beta cells is solely determined by the autoimmune attack or whether other mechanisms such as paracrine modulation, metabolic deregulation and non-immune beta cell apoptosis contribute to T1D pathogenesis is now a matter of debate (Atkinson and Chervonsky, 2012; Atkinson et al., 2015).
  • T1D and T2D are both characterized by a loss of beta cells, which results in a reduced secretion of insulin, failure to control blood glucose levels and hyperglycemia(Brennand and Melton, 2009; Yi et al., 2014).
  • autoimmune response in T1D or insulin resistance/inflammation in T2D lead to a progressive reduction of beta cell mass.
  • Several approaches are currently available to treat T1D and T2D, but none of them aims to target beta cell loss, protect from beta cell injury and preserve beta cell mass, thus preventing diabetes onset.
  • IGFBP3 may also be a mechanism to explain the decompensation observed in patients with T2D, which slowly but steadily lose their beta cell function and stop producing insulin.
  • the chronic IGFBP3 overproduction observed in T2D may favor the destruction of beta cells and lead to the failure for instance of oral anti-diabetic agent.
  • the inventors have also observed that the IGFBP3 receptor (TMEM219) is expressed in murine/human islets, and that its ligation by IGFBP3 is toxic to beta cells, raising the possibility of the existence of an endogenous beta cell toxin ( betatoxin ) that may be involved in the early phase of T1D and in diabetes in general.
  • a non-immunological factor may determine islet/beta cell injuries, and facilitate the exposure of autoantigens to immune cells, thus creating a local inflamed environment and a sustained immune reaction.
  • Liver has been already documented to be the primary source for IGFBP3, and its exposure to inflammation and high glucose levels significantly increases IGFBP3 release in the circulation.
  • IGFBP3 targets islets and beta cells thus favoring their damage and loss.
  • IGFBP3-mediated beta cell injury through the use of newly generated inhibitors of IGFBP3/TMEM219 axis, such as recombinant ecto-TMEM219, may prevent beta cell loss by quenching peripheral IGFBP3, thus blocking its signaling via TMEM219 and halting/delaying T1D progression ( Fig. 32 ).
  • IGFBP3/TMEM219 axis may thus prevent early beta cell injuries associated with the early phase of T1D, by inhibiting binding of IGFBP3 to TMEM219 expressed on the target tissue.
  • inhibitors of IGFBP3/TMEM219 axis may also be considered of benefit in the early treatment of T2D. Therefore, inhibitors of IGFBP3/TMEM219 axis may represent a therapeutic strategy that prevent diabetes onset and protect beta cell from loss and damage thus becoming a relevant clinical option for individuals at risk of developing diabetes, both T1D and T2D, and in those with diabetes in the early stages.
  • Individuals at risk of developing T1D are mainly characterized by the early detection in the serum of multiple autoantibodies against islet peptides, which are usually absent in healthy subjects(Ziegler et al., 2013).
  • T1D T1D
  • individuals are usually relatives (brothers, sisters) of individuals with T1D, but do not have any sign or symptom related to T1D.
  • the probability of progressing to T1D in these subjects within 10 years is high, with the majority of them (70%) developing T1D in the next 15 years, but are often underestimated(Ziegler et al., 2013).
  • Individuals at risk for developing T2D are difficult to identify, especially in the early phase. Prevention consists mainly of lifestyle modifications, which may delay the onset of the disease but could not prevent it (Schwarz et al., 2012).
  • This invention is intended as a new clinical therapeutic agent to be used in individuals at risk for developing diabetes to prevent its onset and in those who are in the early stages of the disease (new-onset) to protect from progression into established diabetes, by counteracting beta cell loss and preserving beta cell mass.
  • inhibitors of IGFBP3/TMEM219 axis are of use in individuals at risk for developing T1D or T2D, and in those with the disease in its early stages.

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